2007: The Year in Review

Advocacy once again was at the forefront of the Academy's activities during 2007. The AAFP took on the federal government, private insurers and regulators to ensure that family physicians' issues were heard and taken into account when decisions were made.

As 2006 drew to a close, Congress narrowly averted a scheduled 5 percent payment cut for family physicians, leading the Academy to immediately jump into the payment fray once again. Early in January, an AAFP-inspired group of 10 medical associations called on Congress to implement comprehensive health system reform that abides by 11 principles, including access to health care, medical liability reform and management of health care costs. The "Principles for Reform of the U.S. Health Care System" calls on Congress "to take action on health system reform this year," said (then) AAFP President Rick Kellerman, M.D., of Wichita, Kan.

In March, the Academy, responding to a report on physician payment rates from the Medicare Payment Advisory Commission urged Congress to replace the current payment structure with a system that compensates physicians for care-coordination services and creates incentives for the establishment of patient-centered medical homes.

By May, Kellerman was testifying before the House Ways and Means Committee's Subcommittee on Health, urging committee members to adopt a Medicare physician payment system that reimburses physician practices for providing a patient-centered medical home. "More than 20 years of evidence shows that having a health care system based on primary care reduces costs and benefits the patient's health," said Kellerman.

May also saw the formal introduction of the Patient-Centered Primary Care Collaborative. Members of the collaborative -- which include the AAFP and other physician groups, health care organizations and employers -- agreed that placing primary care and the patient-centered medical home "center stage" in the health care debate would help put America's ailing health care system back on the road to recovery.

Late in May, some of the nation's largest professional health care organizations, including the AAFP, sent a proposal to Congress asking lawmakers to phase in a repeal of Medicare's sustainable growth rate, or SGR, formula by 2016 if they could not immediately eliminate the program. According to (then) AAFP Board Chair Larry Fields, M.D., of Flatwoods, Ky., Congress needs to create a "stable payment system" for the next few years while working on a "permanent fix for the broken system we have now."

The Academy's efforts continued in July, when Kellerman and other primary care leaders sat down with congressional leaders and asked them to stop the scheduled 10 percent reduction in Medicare payment rates for 2008 and provide positive payment updates in 2008 and 2009. "Everyone agrees this formula does not work," said Kellerman.

For a while in August, it looked as if fixing the payment cuts called for by the SGR would not have to wait until the end of the year when the House passed a bill that would provide slight increases in Medicare physician payments in 2008 and 2009. The provision, which was passed as part of a bill to reauthorize the State Children's Health Insurance Program, or SCHIP, would have provided a 0.5 percent increase in physician payments in both 2008 and 2009. Unfortunately, the payment update did not survive the reconciliation process between the House and the Senate.

With the collapse of the House SCHIP bill, the Academy intensified its advocacy efforts to stop Medicare payment cuts. In September, Kellerman met with staff members in the offices of three senators on the Senate Finance Committee and urged them to support a two-year physician payment increase. "There is a growing understanding that primary care physicians and family physicians in particular are being undervalued in the current system, and that is having an adverse effect on access and quality of care and medical student specialty choice," said Kellerman.

In October, the Academy unveiled a new attitude about advocacy with its "Bold Champions" initiative. The two-year, multimillion-dollar strategic initiative is designed to represent members with assertive actions, forceful language and a new brand identity to telegraph the change in its approach. "This new campaign expresses the AAFP's commitment to play a central role in reforming the health care system for the benefit of all," said newly installed AAFP President Jim King, M.D., of Selmer, Tenn.

The threat to legislation seeking to alleviate the scheduled payment cut spurred the Academy to mobilize its members in November and December. The AAFP urged members to call their senators to stop the pending cuts, and members responded by bombarding Capitol Hill with phone calls saying that Medicare pay cuts were unacceptable. These efforts were rewarded somewhat in the waning hours of December, when the Senate and House passed legislation that provided for a 0.5 percent increase for the first six months of 2008. However, it was a poor attempt at a fix in the Academy's eyes. Congress is engaged in a delaying action, said King, postponing "what needs to happen, which is a complete re-evaluation of the payment system and an elimination of the SGR in order to bring some sanity to our present payment formula."

Throughout 2007, the AAFP kept pressure on CMS and regional Medicare carriers to resolve issues that hamper FPs' efforts to provide good patient care. The Academy's persistence in asking CMS to increase payment to physicians who administer point-of-care hemoglobin A1c testing paid off when CMS agreed to a 55 percent increase in payment in 2007.

The AAFP's efforts again paid off for physicians in Texas, Delaware, Maryland, Virginia and the District of Columbia, who received some payment relief when a Medicare carrier removed wound debridement restrictions from its local coverage determination. In addition, Medicare carriers in Florida, North Carolina, Tennessee and Idaho agreed to the AAFP's requests that they drop an unfairly mandated needle electromyography requirement.

The year also brought several changes in deadlines and requirements for the new National Provider Identifier, as well as print delays with the mandated CMS 1500 claim form. In addition, the Academy kept members informed about how they could successfully participate in the Physician Quality Reporting Initiative to gain a 1.5 percent Medicare bonus.

The Academy learned in February that it had succeeded in thwarting CMS' proposed bundling of CPT urinalysis codes with obstetrical procedure codes. In October, ANN reported that the AAFP was fighting for transparency in CMS' Medically Unlikely Edit project and urging CMS to disclose its edit criteria to physicians.

Throughout the year, Academy leaders and staff members met repeatedly with executives from some of the country's largest health insurance payers to keep the interests of FPs and their patients front and center. AAFP hosted meetings with WellPoint Inc., UnitedHealthcare, Humana Inc., CIGNA HealthCare and Aetna. Hot-button topics included payment for same-day preventive and acute care services; fair payment for purchase and administration of vaccines; physician performance programs; and retail health clinics.

Also this year, CIGNA and WellPoint bent to AAFP pressure and agreed to increase physician payment for vaccines, and AAFP discussions with UnitedHealthcare helped clarify a new lab protocol that at first glance appeared onerous for FPs.

Health information technology remained near the top of AAFP's priority list in 2007 as the Academy formed partnerships and joined initiatives to drive its efforts. In April, AAFP and Revolution Health teamed up to help deliver accurate consumer health information through the Internet. In June, AAFP EVP Douglas Henley, M.D., was tapped as a health care expert to serve on Google's newly formed Google Health Advisory Council. In August, the AAFP and other health care stakeholders launched the Center for Improving Medication Management to help speed the adoption and use of electronic prescribing.

An AAFP survey on electronic health records, or EHRs, showed that FPs continued to lead other physicians in the implementation of EHRs, and in the spring, an IRS ruling cleared the way for EHR donations from hospitals to physicians.

Late in November, Henley's participation in the American Health Information Community, an advisory group working with HHS Secretary Michael Leavitt, helped push through recommendations that called for a series of steps to be undertaken before any future e-prescribing mandate to physicians could be enacted.

In March, three nationally prominent retail health clinic companies signed an agreement supporting the Academy's list of desired attributes for such clinics, while the AAFP made it clear it wouldn't endorse or police such clinics. Members continued to be wary of the clinics, however, and in October, the AAFP Congress of Delegates approved a resolution to amend the introduction to the Academy's "Desired Attributes of Retail Health Clinics" document to read, "AAFP does not endorse retail health clinics and believes that such health care delivery could interfere with the medical home."

The Academy's practice redesign initiative, TransforMED, in conjunction with the Association of Family Medicine Residency Directors, or AFMRD, and the American Board of Family Medicine, named the family medicine residency programs that will participate in the Preparing the Personal Physician for Practice, or P4, initiative. "While many family medicine residency programs are taking new and progressive approaches to physician training, the 14 residencies participating in the P4 initiative will highlight innovations taking place in residencies across the country," said Samuel Jones, M.D., president of the AFMRD and co-chair of the P4 steering committee.

In March, the 2007 National Resident Matching Program, known as the Match, had sobering news for Americans: Although research has documented a current shortage and growing need for family physicians across the nation, the number of U.S. medical school graduates opting for the specialty remains low. After two years of minimal increases in the number of U.S. medical students matching to family medicine residency positions, the 2007 Match saw five fewer filled positions. Also down was the total number and percentage of U.S. students who matched to family medicine. The results show that "there's a detachment between America's medical school production and health care need," said (then) AAFP President Rick Kellerman, M.D.

The news in May 2006 that Duke University was no longer accepting applicants for its family medicine residency program sent shock waves through the family medicine community, so it was a relief to hear in May 2007 that Duke was reviving the program. According to Victoria Kaprielian, M.D., professor and vice chair for education in Duke's community and family medicine department, a key to the revived Duke effort was the P4 initiative that was launched by TransforMED. The residency program was restructured to emphasize community-based continuity clinics.

Oddly enough, it was the war that saved medical education funding in May. A proposed CMS regulation that would have slashed $1.78 billion in federal support for Medicaid graduate medical education, or GME, funding was derailed by legislation funding the war. The CMS proposal would have prohibited states from using federal Medicaid funds for GME, but Congress passed legislation to continue funding the war that also contained a provision prohibiting HHS from promulgating or implementing "any rule or provisions restricting payments for graduate medical education under the Medicaid program" for one year.

In October, medical students and residents learned that the program that historically has helped them defer medical school loans while they were in residency training was under attack. President Bush had signed a bill that replaced the hardship deferment plan with an income-based repayment program and a loan forgiveness plan. However, because of a gap between the end of the deferment program and the beginning of the income-based repayment program, the U.S. Department of Education extended the hardship deferment program until fall 2008. At the same time, legislation to permanently reinstate the loan deferment program was introduced in the Senate.

The introduction of a vaccine for the human papillomavirus, or HPV, caused a big stir in 2006; in 2007, many states were looking at requiring the vaccine for admission to school. The Academy, however, adopted a more cautious tone, saying it was too early to consider mandating the vaccine in the absence of more definitive data about its use and a better understanding about the logistical issues involved in making it available to a sizable patient population. It is "premature to consider school entry mandates for HPV vaccine until such time as the long-term safety with widespread use, stability of supply and economic issues have been clarified, " said an AAFP policy statement. The HPV vaccine was added to the 2007 child and adolescent immunization schedules jointly developed by the CDC, AAFP and American Academy of Pediatrics, however, along with the rotavirus vaccine.

In August, (then) AAFP Board Chair Larry Fields, M.D., approved a recommendation to further expand the routine use of quadrivalent meningococcal polysaccharide-protein conjugate vaccine. Fields' approval of the recommendation was in keeping with a relatively new process that allows the Academy to develop and issue its own provisional immunization recommendations based on a review of provisional recommendations created by ACIP.

After experiencing problems with the supply of influenza vaccine for the past two years, some vaccine suppliers got a jump on the 2007-08 season by prebooking orders as early as last January. Although problems with supplies of influenza vaccine did not materialize, other vaccine shortages caused headaches for family physicians.

In early August, the CDC announced that Merck & Co. Inc. was experiencing delays in shipping both the pediatric and the adult formulations of its hepatitis A vaccine, inactivated. By early October, the company had ceased taking orders for vials of the vaccine.

Then in November, Merck notified the CDC that its Haemophilus influenzae type b conjugate vaccine, sold as PedvaxHIB, was unavailable for shipment. Although ACIP did not call for any changes in overall Hib immunization recommendations at that time, the CDC did announce that it would release limited amounts of PedvaxHIB from its vaccine stockpile. Then in December, Merck announced a voluntary recall of 10 lots of PedvaxHIB and two lots of its combination Hib/hepatitis B vaccine because of contamination concerns. Although no adverse events associated with use of the affected vaccine products were reported, health care professionals were advised to not administer vaccine from the affected lots. The CDC, in consultation with ACIP, the AAFP, and the American Academy of Pediatrics, recommended that physicians and other vaccine providers temporarily defer the routine Hib vaccine booster dose typically administered at age 12-15 months except for children in specific high-risk groups.